Disclaimer: The information contained within the Grand Rounds Archive is intended for use by doctors and other health care professionals. These documents were prepared by resident physicians for presentation and discussion at a conference held at Baylor College of Medicine in Houston, Texas. No guarantees are made with respect to accuracy or timeliness of this material. This material should not be used as a basis for treatment decisions, and is not a substitute for professional consultation and/or peer-reviewed medical literature. Nasal Inverted Papilloma Inverted papilloma is a locally aggressive sinonasal tumor that arises from the outlining Schneiderian respiratory membrane. Ward was credited for reporting the first case of inverted papilloma in 1864. It is a relatively rare neoplasm, constituting 0.5% to 4% of all primary nasal tumors. It has a peak incidence in the fifth and sixth decades of life, but it has been reported in all age groups. There is a male to female predominance in the ratio of 3 to 1. Caucasians are more commonly affected. The etiology of this tumor is unknown. Possible theories include proliferation of nasal polys, allergy, chronic inflammation, environmental carcinogens, and viral infection. Using the techniques of southern blot molecular hybridization, Respler recently reported the presence of human papilloma virus (HPV) type 11. In Weber's study in 1988, all recurrent inverted papilloma were HPV DNA positive, suggesting that the presence of the virus may affect the biological behavior of these epithelial proliferations. Further analysis is need to confirm that HPV is not only a bystander. Grossly, the lesion tends to be firm, polypoid, quite bulky, and more vascular than inflammatory polys. It commonly arises from the lateral nasal wall, usually in the region of the middle meatus and middle turbinate. Its extension into the maxillary and ethmoid sinuses is common. Histologically, the most characteristic feature of inverted papilloma is inversion of the neoplastic epithelium into the underlying stroma. The neoplastic epithelium is most commonly stratified squamous type with minimal mitosis and atypia. Occasionally the respiratory or transitional epithelium can be found. Microcysts containing mucin are occasionally trapped within the epithelium. The tendency of inverted papilloma to recur is well documented. Snyder noted a marked atypia and significant increase in mucous droplets within the epithelium of the recurrent tumors. The incidence of recurrences is directly related to the method of surgical treatment. Limited excision by intranasal polypectomy, turbinectomy, ethmoidectomy, or anterior antrostomy has resulted in recurrence rates of 41% to 78%. In sharp contrast, lateral rhinotomy with medial maxillectomy/ethmoidectomy resulted in recurrence rates of 0% to 14%. The association of inverted papilloma with squmaous cell carcinoma is also well-known. The reported incidence varies widely, ranging from 1.7% to 56%. Many reports document malignant transformation in recurrent inverted papilloma, as well as inverted papilloma and squamous cell carcinoma co-existing in the initial specimen. From this observation, it would seem that squamous cell carcinoma arises from inverted papilloma. Recently HPV type 16 has been associated with invasive squamous cell carcinoma arising from inverted papilloma by in situ DNA hybridization techniques. This suggests that HPV type 16 may be involved in the development of squamous cell carcinoma from pre-existing inverted papilloma. Clinically, the most common symptom is unilateral nasal obstruction followed by epistaxis. Pain, epiphora and proptosis are present in a small number of cases. Many patients have also had one or more surgical procedures, such as nasal polypectomy, before definitive treatment. Physical examination reveals a unilateral nasal mass arising from the lateral nasal wall. A nasal biopsy is needed to confirm the diagnosis of inverted papilloma. Preoperatively, CT scan imaging with intravenous contrast is the diagnostic test of choice. It usually shows opacification of a unilateral nasal cavity as well as the maxillary antrum. Bone destruction commonly involving the medial wall of the maxillary sinus is also demonstrated. The local aggressiveness, high rate of recurrences and associated malignancy are the clinical properties of the inverted papilloma that lead most surgeons to advocate radical surgical removal of these tumors. Currently the surgical technique of choice is an en bloc medial maxillectomy and ethmoidectomy as described by Sessions (1977). This provides complete visual delineation of all tumor margins while preserving the orbital rim, eye, nasal pyramid, and lacrimal apparatus. The medial maxillectomy can be accomplished via either lateral rhinotomy or mid-facial degloving techniques.
An introduction of high resolution CT scanning permitted identification of a select group of patients with limited lesions who may be candidates for more conservative tumor excision. In 1983 Lawson described eight patients whose tumors were localized to the middle or inferior turbinate and corresponding meatus with limited extensions to the ethmoid labyrinth and maxillary sinus. They underwent intranasal or transantral sphenoethmoidectomy. No recurrence were observed after mean follow-up of 8 years. Recently, Waitz and Wigand (1992) reported that most of their patients with inverted papillomas underwent surgery by an intranasal endoscopic approach with the recurrence rate of 17% (6 out of 35), as compared to 19% (3 our of 16) after external operations. The patients in the endonasal surgery group had limited lesions at nonperipheral locations without signs of infiltrative growth. In conclusion, because of the high recurrence rate associated with limited surgical excisions, the treatment of choice for inverted papilloma is an en bloc medial maxillectomy and ethmoidectomy. However, future advancement in diagnostic imaging studies may permit us to select patients who are candidates for conservative therapy. Case Presentation A 66-year-old white male presented with severe, uncontrollable, right-sided epistaxis for which he required anterior nasal packing. His past medical history was significant for coronary artery disease, stroke, and allergic rhinitis. He had experienced chronic nasal congestion for many years. He denied a previous history of epistaxis, hyposmia, and nasal discharge. At the time of evaluation for epistaxis, a friable, pale, pink mass arising from the middle meatus was noted in his right nasal cavity. A biopsy of the nasal mass revealed an inverted papilloma. CT scanning demonstrated a right intranasal mass with nearly complete opacification of the maxillary and ethmoid sinuses. Bony erosion in the right lateral nasal wall was also noted. The patient underwent right medial maxillectomy and ethmoidectomy through a midfacial degloving approach on November 10, 1992. A 3 x 2 x 0.5 cm tan-pink gelatinous mass arising from the nasal wall was noted in the gross specimen. The microscopic examination revealed inverted papilloma without evidence of malignancy. At one month follow-up, the surgical wound was healing well with mild crusting in the nasal cavity. Bibliography Batsakis JG. Tumors of the Head and Neck. Baltimore: Williams & Wilkins, 1979;130-43. Benninger MS, Lavertu P, Levine H, Tucker HM. Conservation surgery for inverted papillomas. Head Neck 1991;13:442-445. Benninger MS, Roberts JK, Sebek BA, Levine HL, Tucker HM, Lavertu P. Inverted papillomas and associated squamous cell carcinomas. Otolaryngol Head Neck Surg 1990;103:457-461. Berghaus A, Jovanovic S. Technique and indications of extended sublabial rhinotomy. Rhinology 1991;29:105-110. Brandsma JL, Steinberg BM, Abramson AL, Winkler B. Presence of human papillomavirus type 16 related sequences in verrucous carcinoma of the larynx. Cancer Res 1986;46:2185-2188. Brandwein M, Steinberg B, Thung S, Biller H, Dilorenzo T, Galli R. Human papillomavirus 6/11 and 16/18 in Schneiderian inverted papillomas. Cancer 1989;63:1708-1713. Buchwald C, Nielsen LH, Ahlgren P, Nielsen PL, Tos M. Radiologic aspects of inverted papilloma. Eur J Rad 1990;10:134-139.
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Inverted papilloma. Ann Otol Rhinol Laryngol 1986;95:215-221. Woodson GE, Robbins KT, Michaels L. Inverted papilloma. Arch Otolaryngol 1985;111:806-811. Yamaguchi KT, Shapshay SM, Incze JS, Vaughan CW, Strong MS. Inverted papilloma and squamous cell carcinoma. J Otolaryngol 1979;8:171-178. Grand Rounds Archive | Department Home page BCM Public | BCM Intranet | Privacy Notices | Contact BCM | BCM Site Map | ©2001-2006 Baylor College of Medicine
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